Unprotected Left Main Coronary Disease Research Articles

Outcomes of Left Main Revascularization after Percutaneous Intervention or Bypass Surgery.

Background This study is aimed at comparing the clinical outcomes of unprotected left main coronary artery disease (ULMCAD) treatment with contemporary percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a “real-world” population. Methods and Results Overall, 558 consecutive patients with ULMCAD (mean age 71 ± 9 years, male gender 81%) undergoing PCI or CABG were compared. The primary endpoint was the composite of death, nonfatal myocardial infarction, or stroke. Diabetes was present in 29% and acute coronary syndrome in 56%; mean EuroSCORE was 11 ± 8. High coronary complexity (SYNTAX score >32) was present in 50% of patients. The primary composite endpoint was similar after PCI and CABG up to 4 years (15.5 ± 3.1% vs. 17.1 ± 2.6%; p=0.585). The primary end point was also comparable in a two propensity score matched cohorts. Ischemia-driven revascularization was more frequently needed in PCI than in CABG (5.5% vs. 1.5%; p=0.010). By multivariate analysis, diabetes mellitus (HR 2.00; p=0.003) and EuroSCORE (HR 3.71; p < 0.001) were the only independent predictors associated with long-term outcome. Conclusions In a “real-world” population with ULMCAD, a contemporary revascularization strategy by PCI or CABG showed similar long-term clinical outcome regardless of the coronary complexity.

Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery.

BackgroundThe use of percutaneous coronary intervention (PCI) to treat unprotected left main coronary artery disease has expanded rapidly in the past decade. We aimed to describe nationwide trends in clinical practice and outcomes after PCI for left main coronary artery disease.Methods and ResultsPatients (n=4085) enrolled in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) as undergoing PCI for left main coronary artery disease from 2005 to 2017 were included. A count regression model was used to analyze time‐related differences in procedural characteristics. The 3‐year major adverse cardiovascular and cerebrovascular event rate defined as death, myocardial infarction, stroke, and repeat revascularization was calculated with the Kaplan‐Meier estimator and Cox proportional hazard model. The number of annual PCI procedures grew from 121 in 2005 to 589 in 2017 (389%). The increase was greater for men (479%) and individuals with diabetes (500%). Periprocedural complications occurred in 7.9%, decreasing from 10% to 6% during the study period. A major adverse cardiovascular and cerebrovascular event occurred in 35.7% of patients, falling from 45.6% to 23.9% (hazard ratio, 0.56; 95% CI, 0.41–0.78; P=0.001). Radial artery access rose from 21.5% to 74.2% and intracoronary diagnostic procedures from 14.0% to 53.3%. Use of bare‐metal stents and first‐generation drug‐eluting stents fell from 19.0% and 71.9%, respectively, to 0, with use of new‐generation drug‐eluting stents increasing to 95.2%.ConclusionsRecent changes in clinical practice relating to PCI for left main coronary artery disease are characterized by a 4‐fold rise in procedures conducted, increased use of evidence‐based adjunctive treatment strategies, intracoronary diagnostics, newer stents, and more favorable outcomes.

Sex Differences in Outcomes After Percutaneous Coronary Intervention or Coronary Artery Bypass Graft for Left Main Disease: From the DELTA Registries.

BackgroundControversy exists over whether sex has significant interaction with revascularization strategy for unprotected left main coronary artery disease. Higher mortality has been reported among women treated with percutaneous coronary intervention compared with coronary artery bypass grafting.Methods and ResultsThe DELTA (Drug‐Eluting Stents for Left Main Coronary Artery Disease) and DELTA‐2 registries are international, multicentric registries evaluating the outcomes of subjects undergoing coronary revascularization for unprotected left main coronary artery disease. The primary outcome was a composite of death, myocardial infarction, or cerebrovascular accidents. The population consisted of 6253 patients, including 1689 (27%) women. Women were older and more likely to have diabetes and chronic kidney disease than men (P<0.05). At a median follow‐up of 29 months (interquartile range 12–49), a significant interaction between sex and revascularization strategy was observed for the primary end point (pint=0.012) and all‐cause death (pint=0.037). Among women, compared with percutaneous coronary intervention, coronary artery bypass grafting was associated with lower risk of the primary end point (event rate 9.5% versus 15.3%; adjusted hazard ratio [AHR], 0.53; 95% CI, 0.35–0.79, P<0.001) and all‐cause death (event rate 5.6% versus 11.7% AHR, 0.50; 95% CI, 0.30–0.82) and no significant differences were observed in men.ConclusionsIn women undergoing coronary revascularization for unprotected left main coronary artery disease, coronary artery bypass grafting was associated with lower risk of death, myocardial infarction, or cerebrovascular accidents whereas no significant differences between coronary artery bypass grafting and percutaneous coronary intervention were observed in men. Further dedicated studies are needed to determine the optimal revascularization strategy in women with unprotected left main coronary artery disease.

Time-Dependent Impact of Sex on the Long-Term Outcomes After Left Main Revascularization.

BackgroundThere are still limited data about the differential effect of sex on long‐term outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery disease. This extended follow‐up study of the MAIN‐COMPARE (Ten‐Year Outcomes of Stents Versus Coronary‐Artery Bypass Grafting for Left Main Coronary Artery Disease) registry evaluated clinical outcomes beyond 10 years.Methods and ResultsOf 2240 patients with unprotected left main coronary artery disease (PCI=1102 and CABG=1138), all‐cause mortality, the composite of death, Q‐wave myocardial infarction, or stroke, and target vessel revascularization were separately evaluated in both sexes. Of 2240 patients, 631 (28.2%) were women and 1609 (71.8%) were men. Women had lower 10‐year incidences of death and serious composite outcomes than men. The adjusted 10‐year risks of adverse outcomes were similar in men. However, the adjusted 10‐year risks were different according to a prespecified period in women. In the short‐term (0–1 year) period, PCI had a significantly lower risk for serious composite outcomes (adjusted hazard ratio [HR], 0.41; 95% CI, 0.19–0.91; P=0.03) compared with CABG. The adjusted risks for death and serious composite outcomes were significantly higher after PCI than after CABG, during the midterm (1–5 years) period (death; adjusted HR, 3.99; 95% CI, 2.01–7.92; P<0.001 and composite outcome; adjusted HR, 2.93; 95% CI, 1.59–5.39; P=0.001). Beyond 5 years, adjusted risks were similar after PCI and CABG in women.ConclusionsIn this 10‐year extended follow‐up study of patients undergoing left main coronary artery revascularization, we observed a time‐dependent impact of sex on the long‐term outcomes after PCI and CABG, especially in women, with significant interactions. However, these results warrant confirmation on larger series of studies.RegistrationURl: https://www.clinicaltrials.gov; Unique identifier: NCT02791412.

Myocardial perfusion imaging in patients with unprotected left main disease.

The management of patients with unprotected left main (LM) coronary artery disease remains challenging, with recent data casting a shadow of doubt on the safety of percutaneous coronary intervention. We aimed at describing the features of patients undergoing myocardial perfusion imaging (MPI) subsequently found to have LM disease. We queried our institutional database for subjects without prior revascularization or myocardial infarction (MI), who had undergone MPI followed by invasive coronary angiography within 6 months, comparing those with evidence of angiographically significant LM disease (i.e. diameter stenosis ≥50%) to those without significant coronary artery disease (CAD), or those with CAD not involving LM. Baseline, stress and imaging features were systematically collected and analyzed, and clinical outcomes (death, myocardial infarction, revascularization) sought. We included a total of 74 patients with LM disease, which were compared with 70 without CAD, and 920 with significant CAD not involving LM. MPI was remarkably safe in all subjects, and significant differences were found for several features, but particularly so for ST change, rate pressure product, and left ventricular ejection fraction (all P<0.05). Most patients with LM disease had moderate or severe ischemia, and the apical, lateral and inferior regions were the most sensitive ones. Clinical outcomes after an average of 35 months were worse in patients with LM disease than in subjects with significant CAD not involving LM, albeit non-significantly, possibly in light of the higher use of coronary artery bypass grafting. MPI is safe and informative in patients with LM disease, and multidimensional appraisal of MPI results may guide decision-making on top of providing prognostic detail and warranty period.

Long-Term Clinical Impact of Intravascular Ultrasound Guidance in Stenting for Left Main Coronary Artery Disease

[Figure: see text].

Impact of prior cerebrovascular events on patients with unprotected left main coronary artery disease treated with coronary artery bypass grafting or percutaneous coronary intervention.

Impact of prior cerebrovascular events on patients with unprotected left main coronary artery disease treated with coronary artery bypass grafting or percutaneous coronary intervention.

Propensity Score Analysis with Partially Observed Baseline Covariates: A Practical Comparison of Methods for Handling Missing Data

(1) Background: Propensity score methods gained popularity in non-interventional clinical studies. As it may often occur in observational datasets, some values in baseline covariates are missing for some patients. The present study aims to compare the performances of popular statistical methods to deal with missing data in propensity score analysis. (2) Methods: Methods that account for missing data during the estimation process and methods based on the imputation of missing values, such as multiple imputations, were considered. The methods were applied on the dataset of an ongoing prospective registry for the treatment of unprotected left main coronary artery disease. The performances were assessed in terms of the overall balance of baseline covariates. (3) Results: Methods that explicitly deal with missing data were superior to classical complete case analysis. The best balance was observed when propensity scores were estimated with a method that accounts for missing data using a stochastic approximation of the expectation-maximization algorithm. (4) Conclusions: If missing at random mechanism is plausible, methods that use missing data to estimate propensity score or impute them should be preferred. Sensitivity analyses are encouraged to evaluate the implications methods used to handle missing data and estimate propensity score.

Four-year outcomes after percutaneous coronary intervention of unprotected left main coronary artery disease in patients with stable angina and acute coronary syndrome.

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

The impact of right coronary artery support on outcomes of patients with unprotected left main disease undergoing percutaneous coronary intervention.

Many operators are discouraged from performing left main (LM) percutaneous coronary interventions (PCI) in the absence of right coronary artery (RCA) support due to the increased procedure risk. We aimed at assessing the impact of absent functional RCA on prognostic implications in patients undergoing unprotected LM PCI. 613 patients underwent LM PCI in our department between 2015 and 2019. Consecutive 385 patients with unprotected LM and at least 1-year follow-up were included in the study. The study population comprosed 272 patients with unprotected left main coronary artery disease (ULMCAD) with dominant RCA, without any significant lesions (Group 1), and 113 ULMCAD patients and without RCA support (Group 2). In Group 2, 32.7% patients had a significant RCA stenosis, 48.7% had chronic total occlusion (CTO) of RCA, and 18.6% had recessive RCA. Patients in Group 2 were older and had higher prevalence of chronic obstructive pulmonary disease (COPD). SYNTAX Score (median [IQR] 26.0 [20.0-33.0] vs 19.0 [13.0-25.5]; P <0.001) was higher and left ventricular ejection fraction was lower (median [IQR] 50.0 [40.0-60.0]% vs 55.0 [45.0-60.0]%; P = 0.01) in this group. All periprocedural complications did not differ among the groups. Long-term all-cause mortality at a median follow-up of 1149 days did not differ significantly (23% vs 20%; P = 0.37). The long-term mortality in CTO-RCA group was also not significantly different. Patients with ULMCAD who have undergone LM PCI in the absence of RCA support, compared with those with ULMCAD and RCA support, differed neither in the prevalence of periprocedural complications nor in long-term all-cause mortality.

Comparison of outcomes for percutaneous coronary intervention in men and women with unprotected left main disease.

BACKGROUNDPercutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery disease (ULMCAD) is increasing strategy in coronary artery patients. However, there is a lack of knowledge on the impact of sex on outcomes of patients undergoing ULMCAD PCI.METHODSFrom January 2004 to December 2015, there were 3,960 patients undergoing ULMCAD PCI at our institution, including 3,121 (78.8%) men and 839 (21.2%) women. The clinical outcome included the incidence of major adverse cardiac events (MACE) (the composite of all-cause death, myocardial infarction (MI), and revascularization), all-cause death, MI, revascularization at three years follow-up.RESULTSCompared with men, women had not significantly different MACE (14.7% vs. 14.6%, P = 0.89, all-cause death (3.5% vs. 3.7%, P = 0.76), MI (5.0% vs. 4.3%, P = 0.38), revascularization (9.1% vs. 8.9%, P = 0.86), respectively. After adjustment, rates of MACE (HR = 1.49; 95% CI: 1.24−1.81;P < 0.0001) and all-cause death (HR = 1.65; 95% CI: 1.09−2.48; P = 0.017) occurred more frequently in male patients, as well as revascularization (HR = 1.46; 95% CI: 1.16−1.85;P = 0.001). CONCLUSIONIn this analysis, compared to men, women undergoing ULMCAD PCI have better outcomes of MACE, all-cause death, and revascularization.

Potential of Circulating Proangiogenic MicroRNAs for Predicting Major Adverse Cardiac and Cerebrovascular Events in Unprotected Left Main Coronary Artery Disease Patients Who Underwent Coronary Artery Bypass Grafting

Objective: This study aimed to explore the association of 14 proangiogenic microRNAs (miRNAs) with major adverse cardiac and cerebrovascular events (MACCE) occurrence in unprotected left main coronary artery disease (ULMCAD) patients who underwent coronary artery bypass grafting (CABG). Methods: A total of 196 ULMCAD patients who underwent first ever CABG were recruited. The peripheral blood samples were collected prior to CABG, and then plasma samples were separated to detect expressions of 14 proangiogenic miRNAs by the reverse transcription quantitative PCR. Patients were regularly followed up to MACCE occurrence or 36 months after CABG. Results: MACCE occurrence at 1 year, 2 years, and 3 years was 7.1, 11.2, and 14.3%, respectively, and accumulating MACCE occurrence time was 32.7 (95% confidence interval: 31.5–33.9) months. Both Kaplan-Meier curves and univariate Cox’s regression analyses displayed that miR-let-7f, miR-19a, miR-126, miR-130a, and miR-378 high expressions were associated with lower accumulating MACCE occurrence. Furthermore, forward stepwise multivariate Cox’s regression disclosed that miR-let-7f high expression and miR-378 high expression independently predicted decreased accumulating MACCE occurrence, whereas BMI (>25.0 kg/m²), diabetes, previous stroke, and higher disease extent were independent predictive factors for elevated accumulating MACCE occurrence. Conclusion: Measurement of circulating proangiogenic miRNAs especially miR-let-7f, miR-19a, miR-126, miR-130a, and miR-378 helps predict MACCE risk in ULMCAD patients who underwent CABG.

Percutaneous coronary intervention in acute unprotected left main coronary artery disease: Provisional strategy or two-stent technique?

Background: Primary percutaneous coronary intervention in acute unprotected left main coronary artery disease, however, tends to be a complex procedure as it lasts longer, requires more expertise, and frequently involves critical bifurcation and often results in more than one stent. Here we present a retrospective analysis of a specific group of patients treated with percutaneous coronary intervention in our center. Methods: Retrospectively 55 patients with unprotected left main coronary artery lesions and acute coronary syndrome diagnosis treated with per cutaneous coronary intervention were identified: The two-stent technique was applied in 28 cases, and provisional stenting (PS) was applied in 27 cases. Results: Current smoking (82.1% vs. 48.1%, p=0.007), prior myocardial infarction (35.7% vs. 7.4%, p=0.010) and prior coronary stent implantation history (28.6% vs. 3.7%, p=0.012) were more common in the two-stent technique group. While procedure duration was higher in the two-stent technique group compared to PS (58.21 vs. 33.15, p<0.001), door-balloon time was lower (29.7 vs. 42.1, p=0.006). However, creatinine levels 48-72 hours post-procedure (1.08 vs. 1.33, p=0.422) and in-hospital mortality rates were similar between the two groups (28.6% vs. 14.8%, p=0.229). Conclusion: In the treatment of acute unprotected left main coronary artery with percutaneous coronary intervention, two-stent technique is a viable, effective and safe strategy as it has similar contrast-induced nephropathy and mortality rates compared to provisional strategy.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Graftinge Among Patients with Unprotected Left Main Coronary Artery Disease in the New-Generation Drug-Eluting Stents Era (From the CREDO-Kyoto PCI/CABG Registry Cohort-3)

Long-term safety of percutaneous coronary intervention (PCI) as compared with coronary artery bypass grafting (CABG) is still controversial in patients with unprotected left main coronary artery disease (ULMCAD), and there is a scarcity of real-world data on the comparative long-term clinical outcomes between PCI and CABG for ULMCAD in new-generation drug-eluting stents era. The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013, and we identified 855 patients with ULMCAD (PCI: N = 383 [45%], and CABG: N = 472 [55%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.5 (interquartile range: 3.9 to 6.6) years. The cumulative 5-year incidence of all-cause death was not significantly different between the PCI and CABG groups (21.9% vs 17.6%, Log-rank p = 0.13). After adjusting confounders, the excess risk of PCI relative to CABG remained insignificant for all-cause death (HR, 1.00; 95% CI, 0.68 to 1.47; p = 0.99). There were significant excess risks of PCI relative to CABG for myocardial infarction and any coronary revascularization (HR, 2.07; 95% CI, 1.30 to 3.37; p = 0.002, and HR, 2.96; 95% CI, 1.96 to 4.46; p < 0.001), whereas there was no significant excess risk of PCI relative to CABG for stroke (HR, 0.85; 95% CI, 0.50 to 1.41; p = 0.52). In conclusion, there was no excess long-term mortality risk of PCI relative to CABG, while the excess risks of PCI relative to CABG were significant for myocardial infarction and any coronary revascularization in the present study population reflecting real-world clinical practice in Japan.

Outpatient Versus Inpatient Percutaneous Coronary Intervention in Patients With Left Main Disease (from the EXCEL Trial)

Prior studies in patients with noncomplex coronary artery disease have demonstrated the safety of percutaneous coronary intervention (PCI) in the outpatient setting. We sought to examine the outcomes of outpatient PCI in patients with unprotected left main coronary artery disease (LMCAD). In the EXCEL trial, 1905 patients with LMCAD and site-assessed low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus coronary artery bypass grafting. The primary end point was major adverse cardiovascular events (MACE; the composite of death, stroke, or myocardial infarction). In this sub-analysis, outcomes at 30 days and 5 years were analyzed according to whether PCI was performed in the outpatient versus inpatient setting. Among 948 patients with LMCAD assigned to PCI, 935 patients underwent PCI as their first procedure, including 100 (10.7%) performed in the outpatient setting. Patients who underwent outpatient compared with inpatient PCI were less likely to have experienced recent myocardial infarction. Distal left main bifurcation disease involvement and SYNTAX scores were similar between the groups. Comparing outpatient to inpatient PCI, there were no significant differences in MACE at 30 days (4.0% vs 5.0% respectively, adjusted OR 0.52 95% CI 0.12 to 2.22; p = 0.38) or 5 years (20.6% vs 22.1% respectively, adjusted OR 0.72, 95% CI 0.40 to 1.29; p = 0.27). Similar results were observed in patients with distal left main bifurcation lesions. In conclusion, in the EXCEL trial, outpatient PCI of patients with LMCAD was not associated with an excess early or late hazard of MACE. These data suggest that outpatient PCI may be safely performed in select patients with LMCAD.

WeChat-based education and rehabilitation program in unprotected left main coronary artery disease patients after coronary artery bypass grafting: an effective approach in reducing anxiety, depression, loss to follow-up, and improving quality of life.

This study aimed to investigate the effect of WeChat-based education and rehabilitation program (WERP) on anxiety, depression, health-related quality of life (HRQoL), major adverse cardiac/cerebrovascular events (MACCE)-free survival, and loss to follow-up rate in unprotected left main coronary artery disease (ULMCAD) patients after coronary artery bypass grafting (CABG). In this randomized controlled study, 140 ULMCAD patients who underwent CABG were randomly assigned to WERP group (n=70) or control care (CC) group (n=70). During the 12-month intervention period, anxiety and depression (using hospital anxiety and depression scale (HADS)) and HRQoL (using 12-Item Short-Form Health Survey (SF-12)) were assessed longitudinally. During the total 36-month follow-up period (12-month intervention and 24-month non-intervention periods), MACCE and loss to follow-up were recorded. During the intervention period, HADS-anxiety score at month 9 (M9) (P=0.047) and month 12 (M12) (P=0.034), anxiety rate at M12 (P=0.028), and HADS-D score at M12 (P=0.048) were all reduced in WERP group compared with CC group. As for HRQoL, SF-12 physical component summary score at M9 (P=0.020) and M12 (P=0.010) and SF-12 mental component summary score at M9 (P=0.040) and M12 (P=0.028) were all increased in WERP group compared with CC group. During the total follow-up period, WERP group displayed a trend of longer MACCE-free survival than that in CC group but without statistical significance (P=0.195). Additionally, loss to follow-up rate was attenuated in WERP group compared with CC group (P=0.033). WERP serves as an effective approach in optimizing mental health care and promoting life quality in ULMCAD patients after CABG.

Long-term outcomes of single stenting compared with double stenting strategy for unprotected left main coronary artery disease: A protocol for systematic review and meta-analysis.

Background:The optimal interventions for unprotected left main coronary artery (ULMCA) disease have long been debated, and long-term clinical studies comparing single stenting to double stenting strategies for ULMCA are currently lacking.Methods:We plan to perform a systematic review and meta-analysis of clinical trials comparing single stenting with double stents strategy for ULMCA disease. We will search PubMed, EMBASE, Web of science and Cochrane Library using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Two reviewers will screen retrieved records, extract information and assess the risk of bias independently. STATA software will be used to conduct data synthesis. There is no requirement of ethical approval and informed consent.Results:This study will be submitted to a peer-reviewed journal for publication.Conclusion:We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.Ethics and dissemination:Ethics approval and patient consent are not required, as this study is a systematic review and meta-analysis.INPLASY registration number:INPLASY2020110030

Risk stratification in unprotected left main coronary disease: do we have the tools?

Abstract Introduction The evolution of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) techniques made the choice of the optimal revascularization strategy of unprotected left main coronary disease (ULMD) challenging. Scoring systems are useful tools for the decision-making process and for risk stratification. Purpose To evaluate 1) the performance of the SYNTAX score I (SSI) and II (SSII) and Euroscore II (EII) in risk stratification and 2) the outcome predictors of patients (pts) with ULMD, according to the treatment strategy chosen (PCI or CABG). Methods Retrospective single centre cohort study of 440 consecutive pts (age 68±11 years; 76.6% male) with significant ULMD (defined as left main coronary artery stenosis &amp;gt;50%, with no patent arterial or venous bypass graft to left anterior descending artery), who were submitted to PCI (n=135) or CABG (n=307), between January 2006 and December 2018. Median follow-up (FU) was 4.0±1.8 years. The primary outcome was a composite of cardiovascular (CV) death, non-fatal myocardial infarction (MI) and target lesion revascularization (TLR). Results During the FU period, there were 112 (25.5%) CV deaths, 26 (5,9%) non-fatal MI and 53 (12.0%) TLR. Multivariate analysis of pts submitted to PCI showed that SSII and anatomical complete revascularization were independent predictors of the primary outcome (HR 1.045, CI 1.015–1.075, p=0.003 and HR 3,014, CI 1.655–5.489, p&amp;lt;0.0001, respectively). The 63 pts submitted to PCI, who had a SSII favoring CABG, had slightly more adverse events (42.9% vs 41.7%, p=0.889). In the CABG cohort, only SSII was an independent predictor of the outcome by multivariate analysis (HR 1.061, CI 1.035–1.086, p&amp;lt;0.0001). The ROC curve analysis for all cohort presented no discriminative capacity for SSI (AUC 0.538, CI 0.482–0.593, p=0.186) and a weak discrimination for SSII (AUC 0.659, CI 0.605–0.713, p&amp;lt;0.0001) and EII (AUC 0.653, CI 0.599–0.707, p&amp;lt;0.0001; Figure 1). The difference between SSII and EII was not statistically significant (DeLong test p=0.828). Similar results were found when analysing the CAGB group, however, in PCI cohort, SII and EII showed an acceptable discriminative capacity (AUC 0.722, CI 0.636–0.809, p&amp;lt;0.0001 and AUC 0.700, CI 0.610–0.791, p&amp;lt;0.0001, respectively). Conclusion In a real-world ULMD population, the most common risk scores, mainly those integrating anatomical and clinical features, presented a very modest role in the risk stratification, both in chronic and acute coronary syndromes. However, in pts with ULMD submitted to PCI, those risk scores had a more significant role in the risk stratification of these pts. Figure 1. SSI, SSII, EII ROC curves for all cohort Funding Acknowledgement Type of funding source: None

Prognostic analysis of drug-eluting stent implantation and coronary artery bypass grafting in patients with unprotected left main coronary artery disease complicated with chronic renal failure

To analyze the long-term prognosis of undergoing drug-eluting stent implantation (DES) or coronary artery bypass grafting (CABG) in patients with unprotected left main (ULM) coronary artery disease complicated with chronic renal failure (CRF). Patients with UML coronary artery disease complicated with CRF admitted to the department of cardiology intensive care unit (ICU) and cardiac surgery ICU of Beijing Anzhen Hospital Affiliated to Capital Medical University were enrolled. According to the estimated glomerular filtration rate (eGFR), the patients were divided into two layers, and the clinical characteristics of DES patients and CABG patients were analyzed. Log-Rank method and Cox regression were used to analyze the coronary artery disease and long-term clinical prognosis of patients with two surgical strategies. A total of 353 patients were enrolled, including 150 patients with eGFR < 45 mL×min-1×1.73 m-2 (DES 67 cases, CABG 83 cases), eGFR 45-59 mL×min-1×1.73 m-2 in 203 cases (DES 80 cases, CABG 123 cases). In terms of demography and clinical history, compared with CABG group, DES group had lower proportion of complete revascularization and lower proportion of chronic totalocclusion (CTO) and multi vessel disease in each eGFR level. All patients were followed up for an average of (30.74±15.05) months. Log-Rank analysis showed that there was no significant difference in the incidence of major cardiovascular and cerebrovascular adverse events (MACCE), all-cause death, cardiogenic death and stroke between DES group and CABG group in each eGFR level. In eGFR 45-59 mL×min-1×1.73 m-2, the proportion of target vessel revascularization (TVR) in DES group was higher than that in CABG group (18.8% vs. 0.8%, P < 0.01); in eGFR < 45 mL×min-1×1.73 m-2, the incidence of myocardial infarction in DES group was higher than that in CABG group (10.4% vs. 1.2%, P < 0.05). Cox analysis showed that after adjusting for age, gender, history of hypertension, diabetes, left ventricular ejection fraction, smoking history, previous cerebrovascular disease, complete revascularization, multiple vessel disease and CTO, TVR proportion in DES group was still higher than that in CABG group in eGFR 45-59 mL×min-1×1.73 m-2 [hazard ratio (HR) = 46.463, 95% confidence interval (95%CI) was 4.558-473.693, P = 0.001]; in eGFR < 45 mL×min-1×1.73 m-2, the incidence of myocardial infarction in DES group was still higher than that in CABG group (HR = 14.098, 95%CI was 1.123-176.988, P = 0.040), there was no difference in TVR proportion between the two methods. eGFR < 45 mL×min-1×1.73 m-2 is an independent risk factor for DES in ULM patients. DES is safe and effective for ULM patients with CRF, but for patients with more severe CRF (eGFR < 45 mL×min-1×1.73 m-2), there was more myocardial infarction in DES group than that in CABG group, which should be carefully selected.

Four-year outcomes of unprotected left main lesion treated with one-stent versus two-stent technique

Introduction – Most reports on left main bifurcation lesions have demonstrated that treatment with a singlestent strategy is superior to a two-stent strategy but have excluded patients with acute coronary syndromes (ACS). Aims – The aim of the current study was to compare the four year outcomes of patients with unprotected left main coronary artery disease (ULMCAD) treated by percutaneous coronary intervention (PCI) with a one-stent or two-stent strategies in a population including those presenting as ACS. Methods – A total of 135 patients with ULMCAD treated by PCI were included, of which 75 (55.6%) had a one-stent strategy (Group A) and 60 (44.4%) had a two-stent strategy (Group B). Results – Fewer patients in Group A had a TIMI III flow at the end of the procedure (89.4% vs 100%, p=0.03) and complete revascularization (65.3% vs 88.3%, p=0.002). We found a higher early mortality in Group A without reaching statistical significance (13.4% vs 3.3%, p=0.1). Mortality rate at 4-year follow up was higher with Group A after multivariable analysis (adjusted HR 0.36, CI 0.15-0.85, p=0.02). We found no significant differences between the groups in terms of major adverse cardiac event (MACE) (adjusted HR 0.85, CI 0.34-1.48, p=0.7) or target lesion revascularization (TLR) (adjusted HR 1.37, CI 0.42-4.47, p=0.6) at 4-year follow up. Conclusions – Among unselected patients with ULMCAD PCI, with or without ACS, the early mortality rate is similar between one and two-stent strategy. Although, 4 year TLR and MACE rates were similar between the two groups, the 4-year all-cause mortality rate was lower in the two-stent strategy group.